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Peter Lehmann & Craig Newnes (eds.)

Withdrawal from Prescribed Psychotropic Drugs

Preface by David L. Richman

David L. RichmanDavid L.
Richman M.D.
Before writing the preface for this new work about the withdrawal of psychiatric drugs edited by Peter Lehmann and Craig Newnes, I started by reading Peter's book "Coming Off Psychiatric Drugs" first published in 1998 with a 5th English E-edition in 2021. I had not known of Peter Lehmann and I was also not aware of his work on psychiatric drug withdrawal. His book was filled with powerful first-person accounts of heart-rending personal trials and tribulations within the world of psychiatric drugs with a focus on the oft-ignored issue of drug withdrawal and with reports of professionals, working in psychotherapy, medicine, social work and natural healing how they help in the withdrawal process. It led me to resources I was also unaware of such as International Institute for Psychiatric Drug Withdrawal (IIPDW), and the many people internationally grappling this issue. Peter Lehmann's summary chapter was a serious and well researched attempt to provide an overview of the various categories of psychiatric drugs, withdrawal practices and resources. Then I reviewed the proposed table of contents for his new work and its expanded individual chapters on the various categories of psychiatric drugs, the look at professional and self-help strategies, and various approaches to the multitude of problems that can occur in an attempt at drug withdrawal. There is still a dire need for education and the provision of both avenues of support and specific tools and approaches to this complex issue. I applaud Peter and Craig for their efforts.

But first, who is Dr. Caligari?

I am a Board-Certified Psychiatrist (American Board of Psychiatry & Neurology), who went to The New York University School of Medicine, graduating in 1970. I then did an internship and Psychiatric residency in Northern California where I had moved. After working in a community clinic (La Clinica De La Raza) for many years, I started working for Kaiser-Permanente (among the largest non-profit Health Maintenance Organizations in the USA) in Northern California as a psychiatrist/psychopharmacologist from 1992-2008. From the mid-1970s and onward, to be a psychiatrist meant you managed the prescribing of psychiatrist, and the therapy was left to lowered paid mental health professionals. This trend has only sped up to the present day, so a psychiatrist practicing only psychotherapy is a rare bird indeed in the USA. Thus, there are many pressures subtle and not so subtle to prescribe, not to Not prescribe.

Since my retirement I have kept my medical license active on a volunteer basis only and besides being my neighborhood emergency coordinator (earthquakes, wildfires and now Covid19), I have not practiced psychiatry since 2008. It was in 1970 while doing an internship at San Francisco General and also volunteering at a "free clinic" that my wife Sherry Hirsch and I first connected with Wade Hudson, Leonard Frank and others and started Madness Network News (MNN) "All the fits that's news to print". The name is a reference to Ronald D. Laing's and David Cooper's Philadelphia Association of London and their "Network Newsletter" which I experienced in London in 1969 as they were trying to create alternatives to the psychiatric establishment with therapeutic places like Kingsley Hall – see the book "Two Accounts of a Journey Through Madness" by Mary Barnes and Joseph Berke. We published "The Madness Network News Reader" in 1974. We then also founded NAPA (The Network Against Psychiatric Assault). NAPA was based on our mutual experiences and concerns about psychiatry and its real potential for abuse, from the point of view of patients, professionals, and family members. The name was a play on the Napa, California state psychiatric hospital of the same name.

I started to write articles for MNN in 1971 about psychiatric drugs and drugging under the pen name Dr. Caligari from the classic German silent film. In the film Dr. Caligari is either a mad scientist with his somnambulist Cesare (comparable to a drugged patient) carrying out violent acts at Caligari's behest or the benevolent "Alienist" (prior term for psychiatrist) director of a psychiatric hospital. One aspect of the articles I wrote had to do with withdrawal from psychiatric drugs. In 1984, MNN published my "Psychiatric Drugs" booklet and I wrote an unpublished manuscript "Tranquilizing Madness". During my career as a practicing psychiatrist/psychopharmacologist I faced the Sisyphean task of trying to care for and help people while Doing No Harm. I worked hard to educate people, to look head on at the difficult decisions in using or not using psychiatric drugs in order to help manage the complex personal, familial, cultural, life and human problems at hand, and to be as compassionate, caring and understanding as I could be. It's also important to not just stereotype all psychiatrists and mental health professionals as Dr. Caligaris or nurse Ratcheds (the tyrannical nurse in "One Flew Over The Cuckoo's Nest"). Most are serious professionals trying to help people however misguided their ultimate effects might be.

There is so much that could be said about starting, not starting, stopping psychiatric drugs. Withdrawal can occur or be needed for many reasons including: a serious adverse reaction, significant and disturbing side effects, lack of effect, avoiding long term damaging effects, trying to figure out if a drug is really needed or if an acute problem has passed, and the list goes on. The use of psychiatric drugs entails the withdrawal reactions of various types as well as the side effects, adverse reactions, potentially life-threatening problems like anti-psychotic induced neuroleptic malignant syndrome (NMS), and long-term risks of anti-psychotics like tardive dyskinesia.

One rule of thumb was that the faster a drug is absorbed and then metabolized and excreted the more likely a withdrawal reaction (the drug half-life). Examples include minor-tranquilizer/sedative-hypnotic/benzodiazepine drugs like Xanax (alprazolam), or the anti-depressant Effexor (venlafaxine). However, there are very significant individual differences, genetically determined and involving the liver's enzyme systems for drug metabolism. When I was practicing there was no way to test for those who might be slow or rapid metabolizers. Lithium is the exception as an inorganic element which is not metabolized and it is the kidney that regulates the excretion and removal from one's system. There are now genetic tests available (not cheap) that can determine these individual genetic differences. I don't know how widely used they are, but they can help to determine a person's unique profile and affect potential starting doses. In an ideal medical world, anyone potentially going on a psychiatric drug would be tested before medications are started.

However, unlike an antibiotic affecting a relatively simple organism, and where everyone will get the same standardized dose; when it comes to human brains there is an enormous variability in one's response to any psychoactive drug! And this is above and beyond simple liver metabolism and blood levels of the drug. So, whether it is alcohol, narcotics, cannabinoids, psychedelics, psychiatric drugs, etc. there is no simple way to predict a person's sensitivity and the drugs ultimate effects. Only by an actual trial of the drug, using a test dose in your own biological system can you begin to figure this out.

There are also the effects of age, gender, ethnicity. The adage for the elderly had always been "start low and go slow" as far as drug dosing, but I think it is applicable still today for all who might use psychiatric (or any psychoactive) drug even if one gets genetic testing of drug metabolism. Ask anyone who has ended up with problems or an emergency room visit after using edible marijuana products to begin to appreciate individual response patterns and the potential for unanticipated outcomes. Know the drug, know your own responsiveness as much as you can and yes, start low and go slow.

Reading Peter Lehmann's book "Coming Off Psychiatric Drugs" will give you many first-hand accounts for the many problems that I also saw that can occur with psychiatric drugs. The withdrawal reactions were potentially horrendous (a non-medical term, however still apt) and often led to a cessation of any attempt to continue the withdrawal. It soon became obvious that for such drugs extremely slow and totally individualized drug tapers were needed with a great deal of structure, patience and individualized titration of progressively smaller and smaller doses with a systematic trial and error process a necessary component after an initial withdrawal schedule is made. And given the common practice of polypharmacy (using multiple psychiatric drugs), there is also no simple formula for which drug to begin withdrawal from when multiple meds are being consumed.

In my MNN Dr. Caligari writings and the 1984 drug booklet ("Dr. Caligari's Psychiatric Drugs"), I outlined a 10% generic formula for drug withdrawal schedules. Of course, 10%-steps are not to be understood as a rule of speed, but only as a proposal. In essence when considering withdrawal, with whatever dose a person was on, start by reducing the dose by 10% and then after some period of time, say 1-2 weeks or longer, evaluate any problems. Separating drug withdrawal from any return of prior problems or a brain supersensitivity and related symptoms created by the use of the drug and exposed during drug withdrawal is not necessarily easy, to say the least. Going as slow as a person needed (weeks, months or even years), returning to the last dose when feeling stable if problems emerge before re-starting gradual dose reduction, etc. were all strategies. At times it required the mechanical process of going to the lowest dose of the drug manufactured and then cutting pills into quarters, and other such unorthodox ways to individualize progressively smaller doses. Dealing with tablets with hard coatings, capsules, etc. and limited dose ranges manufactured were among the problems.

I was glad to read in Peter Lehmann's book and other sources of ways now being used or suggested to manage this better such as tapering strips or working with pharmacists to hand tailor small drug doses and decrements. Another option was converting such a short acting drug like Xanax with a short half-life to a drug with similar properties or nearly identical properties but with a much longer half-life that would by its chemistry leave the body and brain much slower such as Klonopin (clonazepam). That is not to say this obviated all problems, which it didn't, as prolonged or just "long" enough use (which can vary enormously from one person to the next) and physiologic dependence are never simply solved for all kinds of reasons.

This is just one, albeit a very important, aspect of drug withdrawal, but all drugs in many different ways regardless of their half-life have by their nature an impact on the neurotransmitter systems of the brain (serotonin, dopamine, norepinephrine, etc.) and use over time can create problems when discontinued and by how they are discontinued. And all of this is occurring in the complex context of human beings and the human condition. Given all of this, the need for education, support on many levels, cooperative problem solving, etc. becomes a needed part of the entirety of helping someone to enter the process of withdrawal. I am glad that people like Peter Lehmann, organizations like IIPDW and others have been attempting to rectify what had been an enormous vacuum.

Today, even though I have not actively practiced medicine since 2008, I do follow the medical-psychiatric literature from a distance and in fact not much has changed in the world of psychiatric medications. More "me too" drugs (drugs that are derivatives of the same basic chemical formula and with similar or identical drug effects and properties) in most all categories of psychiatric drugs; aside from the use of ketamine for treatment-resistant depression – to say nothing of tools like transcranial magnetic stimulation (TMS), not to be confused with ECT (electroconvulsive therapy / electroshock) which should be relegated to the dust bin. We can do better!

During my years practicing as a psychopharmacologist I constantly faced the conundrums and difficult decisions inevitably present around the use of psychiatric drugs and did my best to care for people. But there is no cookie cutter approach in this arena. You can't just say No to any and all use of psychiatric drugs as the way to avoid concerns like dependence and withdrawal. Not everyone has necessarily been damaged by psychiatric drugs and like any tool it can be used constructively or destructively but looking at the balancing scale of constructive vs destructive for any person is not just a simple objective evaluation (much more could be said about this). What is the legitimate use of lithium, atypical anti-psychotics, anti-depressants, psychostimulants, sedative-hypnotics? What about cannabinoids, psychedelics, substituted amphetamines like MDMA, ayahuasca, mescaline? There is no simple answer, but one can go just so far towards optimizing health and wellbeing and managing life's problems with any exogenous substance.

Berkeley, October 18, 2020

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